discharge process for a patient with a tracheostomy from

Tracheostomy Discharge Policy Discharge process for a patient with a Tracheostomy from Salford Royal Foundation Trust

Reference Number: TWCG11(18) Issue No 2 Issue Date: 16/09/2019 of 18

It is your responsibility to check on the intranet that this printed copy is the latest version

Tracheostomy Discharge Policy

Discharge process for a patient with a Tracheostomy from Salford Royal Foundation Trust

Lead Author: Claire Cooke Physiotherapist and Sara Whitfield Physiotherapist

Additional author(s) Dr Anna Perks, Dr Krystyna Walton, Kate Hindley, Ann Dawn Hulmes,

Dr Andrew Deacon

Division/ Department:: Surgery & Tertiary Medicine

Applies to: (Please delete) Salford Royal Care Organisation

Date approved: 02/09/2019

Expiry date: September 2022

* This includes documents relevant to multiple Care Organisations, Corporate and Support Services

Contents

Contents

Page

1 What is this policy about? 2

2 Where will this document be used? 2

3 Why is this document important? 2

4 What is new in this version? 2

5 Policy

Executive Summary 3

5.1 Discharging a patient from hospital with a tracheostomy 3

5.2 Discharge Process 3

5.3 Determining discharge location 4

5.4 Determining a patient’s ability to self care 4

5.5 Long-standing tracheostomies 5

5.6 Provision of training for patients with capacity 5

5.7 Training documentation 6

5.8 Provision / equipment for discharge 6

5.9 Referral to North West Ambulance Service 7

5.10 Tracheostomy Passport 7

5.11 Community Management 7

5.12 Follow-up after discharge 7

6 Roles and responsibilities 8

7 Monitoring document effectiveness 8

8 Abbreviations and definitions 8

9 References and Supporting Documents 9

10 Document Control Information 11

11 Equality Impact Assessment (EqIA) screening tool 13

Appendices Appendix 1: North West Ambulance Service Referral Form 15

Appendix 2: Tracheostomy Passports 18

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




1. What is this policy about? 161.2 The purpose of these guidelines is to develop a proactive process for discharging a

patient with a tracheostomy in a timely and efficient manner. This document should be

used by all health care professionals involved in discharging a patient with a

tracheostomy.

There are an increasing number of patients being discharged from hospital with a long term tracheostomy. Discharge destinations may include a patient’s own home, or nursing home. It is essential that the patient and/or carer and community staff have the skills, knowledge and competencies to care for this complex group of patients. New and established tracheostomies are at risk of complications, but good routine care should avoid complications. This document specifies the core skills required by the patient or carer prior to discharge from hospital in order to provide safe care and the requirements to ensure best practice. It also sets out requirements for training and education surrounding tracheostomies. It also lists the essential equipment which must be ordered for the patient. This is to ensure a safe discharge from hospital.

2. Where will this document be used?

This document is intended for all staff who are involved in the management of patients with a long term tracheostomy who are due to be discharged from hospital to the community setting or going on periods of home leave (for example neuro rehabilitation wards and neurosurgery ward H7). If you are in an area where you are not completing this task regularly liaise with staff on neurosurgery and neuro rehabilitation wards for more information.

3. Why is this document important?

3.1 A tracheostomy is an opening in the anterior wall of the trachea, below the larynx.

Indications include:

Airway maintenance and protection (e.g. bulbar dysfunction; upper airway obstruction,

such as facial or neck trauma; reduced level of consciousness)

Secretion clearance (e.g. excessive secretions, poor cough effort)

4. What is new in this version?

4.1 N/A




5. Policy

Executive Summary:

This document sets out the process which all staff must follow in order to discharge a patient

with a tracheostomy safely from an acute hospital care setting into the community (which may

include a care home or patient’s own home.) This could include patients on a rapid discharge

pathway for palliation.

5.1 Discharging a patient from hospital with a tracheostomy

5.1.1 Planning the discharge of a patient with a tracheostomy is a complex process, involving close liaison with the patient’s community team and ensuring the right specialist equipment is provided for the patient. The patient and carers must be trained on the ward to feel confident in the day-to-day care and management of their tracheostomy tube. Salford Royal NHS Foundation Trust is unable to provide training for external care providers (for example nursing homes and private care providers in the community). Therefore staff members will not be able to provide any training to care providers that are accepting patients being discharged to long term care facility or care agency. The care facility or agency will be responsible for all on-going management and training of their own staff to enable them to accept these complex patients. Discharge planning and implementation should begin as early as possible. The complexity of the plan is determined by the patient’s medical condition and clinical requirements. Members of the discharge planning team should meet and their responsibilities identified. A coordinator should be allocated to coordinate the discharge process. This would normally be a member of the integrated discharge team.

5.2 Discharge Process

5.2.1 There are 3 stages to the discharge process. These are:

(1) Evaluation of the patient to ensure they are medically optimised for discharge

(2) Discharge destination to be decided dependent on a number a number of factors such as

continuing health care (CHC) funding and patient needs in liaison with the multi-

disciplinary team (MDT)

(3) If funding is required, ensure this is in place prior to discharge. If a patient meets

continuing healthcare funding requirements, the funding needs will be identified by the

local Clinical Commissioning Group (CCG) through the continuing healthcare process.

The CCG should complete a risk assessment to ensure discharge is planned to an

appropriate location.




5.3 Determining discharge location

5.3.1 The discharge location must be considered to be safe and appropriate to accommodate care and future management of the tracheostomy (with regard to medical condition, care needs and prognosis).

Factors that will influence the identification of an appropriate discharge location include:

Medical condition, clinical stability, prognosis and clinical requirements

Ability to self-care

Carer preparation/education

Patient’s Capacity

Factors that need to be considered when determining the discharge destination:

Would the tracheostomy be safely managed in the environment?

How often are tracheostomy cares and suction required?

What is the risk of tracheostomy occlusion or dislodging?

How would the patient call for help?

This policy must therefore be followed in order to assist with determining the recommended discharge location.

5.4 Determining a patient’s ability to self care

5.4.1 The MDT, must perform a thorough risk assessment, covering the quick reference guide below and any other factors they identify as relevant to the ability of the patient to care for him or herself. That assessment must be comprehensively documented and agreed with the patient: QRG Determining an individual’s ability to self-care for their tracheostomy If there is any doubt regarding a patient’s capacity to make decisions about their tracheostomy care, a full capacity assessment should be completed with a Clinical Neurological Psychologist [if required jointly by the treating team (a Specialist Nurse, Physiotherapist, speech therapist and/or Occupational Therapist)]; in accordance with the provisions of the Mental Capacity Act 2005 (“MCA”). If a patient is deemed able to self-care, they must be willing to accept the risk of managing their own tracheostomy if the wish to be discharged home. It would be reasonable for relatives to receive tracheostomy training on request, but the overall responsibility lies with the patient. If the patient has capacity and the provision of training to enable them to provide self-care is considered appropriate, training provided should follow the process set out in this policy. If the patient is assessed as lacking capacity, they will require 24/7 care by tracheostomy-competent staff. If this care setting is the patient’s home, then it would not be appropriate to rely on relatives to deliver any of this care. It would be reasonable for them to receive some support if they wished to be involved. Tracheostomy training is disseminated via the district nurses to carers within Salford Health Care, as per the main tracheostomy policy. Outside Salford Health Care, local training of carers is managed by the appropriate CCG and out of the




control of the hospital. It will be the decision of the patients local CCG to determine if funding of 24/7 carer support at home is appropriate for the individual patient.

5.5 Long-standing tracheostomies

For patients who come into hospital with existing arrangements for their tracheostomy in the community, these arrangements should be reviewed to ensure they are still safe. This may apply to children and young adults with long-term conditions.

5.6 Provision of training for patients with capacity

Training should only be provided to patients or family members or carers of those patients that have the capacity accept the risks associated with leaving the hospital environment. The patients capacity should be assessed jointly by the MDT as discussed in section 5.4.1. If the patient is assessed as lacking capacity, they will require 24/7 care by tracheostomy-competent staff either at home or in a continuing health care facility. SRFT would not be able to formally train the patient, family members or carers to complete tracheostomy cares, as the patient would not be able to accept this risks associated with leaving the hospital environment and training needs associated with this. A key worker should be allocated the task of coordinating the discharge process to ensure the training needs set out in this policy are carried out and signed off when the patient or carer feels confident and can demonstrate that he or she can safely perform all necessary care tasks: QRG Core tracheostomy training topics for patient and/or carer.

They will also be responsible for ensuring that all essential equipment is ordered and collated by the team looking after the patient before the patient is discharged: QRG Tracheostomy discharge equipment guide with order codes Members of the discharge planning team must ensure each section of the education content is completed, and this should be overseen by the allocated key worker. The discharge checklist must be printed off, completed and signed for each patient. This should be a working document, please place a copy in the patient’s file, and sign each section when it has been completed: QRG Tracheostomy discharge risk assessment The keyworker who is coordinating the process should ensure that each section is completed by the delegated member of the discharge planning team.

Trainers Training to patients should only be provided by those suitably qualified to do so. In particular, the trainers must be: • Confident managing and caring for tracheostomy patients • Completed both Basic Tracheostomy Training and Emergency Tracheostomy Training study sessions. • Competent to provide training Those providing training should be assessed in relation to the above competencies prior to commencing the role of trainer. It is the duty of those providing training to ensure that they maintain their competencies in this area with annual refresher training.

Prior to commencing training, the risk assessments outlined earlier in this policy must have been

fully completed and signed by the necessary individuals.




Education will be provided in the ward environment under close supervision, as detailed: QRG Core tracheostomy training topics for patient. The documentation of core tracheostomy training must be completed and signed off by the trainer only once the patient can demonstrate they can perform all care tasks safely. Some sections may well be carried out by different trainers, once all sections have been completed the key worker should sign the form to ensure all training sections have been completed.

5.7 Training documentation

A record must be kept by trainers of the techniques that were taught to the patient. Those techniques should be in line with current clinical guidance and best practice. This should be filled in the patients paper notes. All patients should be provided with supporting documentation which they can refer to at home. This will include details of relevant numbers which the patient and/or their carer can use to obtain post-discharge support. Upon provision of this information to the trainee, the trainer must obtain the signature of the trainee to confirm receipt using blank proforma: QRG Core tracheostomy training topics for patient and/or carer.

5.8 Provision / equipment for discharge

Irrespective of the destination, the key worker coordinating discharge will be responsible for ensuring the essential tracheostomy equipment is ordered and collated before the patient is discharged. Each patient should be discharged with a minimum of 2 week supply of equipment: QRG Tracheostomy Equipment required for discharge (patient’s home or continuing healthcare facility). QRG Tracheostomy discharge equipment guide with order codes If discharging to a continuing health care facility, written confirmation should be provided that that they can complete all cares, including tracheostomy tube changes. They are responsible for sourcing all the tracheostomy equipment requirements and this should be confirmed prior to discharge. The quick reference guides above may be provided to the facility to ensure this is done. If discharging a patient home, the key worker is responsible for ensuring that the relevant equipment is ordered in time for discharge. Referral to the District Nursing Service should be made as early as possible, as some of the equipment will need to be ordered from the District Nursing Service. However, not all district nurses in the Greater Manchester area will be experienced with tracheostomy care therefore the MDT need to liaise in advance to determine what local teams are able to provide.




The key worker coordinating the discharge should make the patient aware that they could qualify for free prescriptions, as most of their equipment can be ordered directly from their GP via their local pharmacy or countrywide supplies. This is a free delivery service from a company that delivers basic equipment on prescription. The district nurse in their local area will need to register the patient with this company prior to discharge and they will need to allow 5-7 days for delivery. It needs to be made clear to the district nursing team that a patient will only be discharged with 2 week supply of equipment. Tracheostomy tubes are not available on prescription. Therefore, the district nurses will need to order these. The key worker will need to ensure an accurate handover and supply the patient with spare tubes on discharge (i.e. one same size, and one of a size below).

5.9 Referral to North West Ambulance Service (NWAS)

To ensure a timely response if an emergency arose in the community setting, each patient should be registered to the NWAS Inform scheme [See appendix 1]. The referral form must to be filled in and faxed to North West Ambulance Service by a delegated member of the discharge planning team. A copy must to be kept in the patient’s paper medical notes. The patient and / or their carer should be informed of this arrangement and the reasons for it.

5.10 Tracheostomy Passport

Each patient should be given their own tracheostomy passport [See appendix 2], which determines the need for tracheostomy and key requirements for each specific patient. The patient and/or their carer should be informed of the purpose of the passport and advised to keep it easily accessible to any care professional (eg. Ambulance service or hospital facility) who may subsequently need to attend to the patient in an emergency. The Ambulance Paramedics are not all tracheostomy trained, therefore the patient will be taken to Accident and Emergency for all emergency care.

5.11 Community Management

Management within Salford Health Care is included in the main policy, where a series of quick

reference guides are included. All NHS staff responsible for caring for patients with

tracheostomies in the community will be expected to complete a tracheostomy management

(competency training and assessment) pack and annual update.

Tracheostomy & Laryngectomy MAIN DOCUMENT. Policy number TWCG16 (11)a

For patients being discharged out of area, care should be made to ensure the discharge

destination is safe, then ongoing management will be guided by their own local policies.




5.12 Follow-up after discharge

Coordinated by the Head and Neck CNS team, patients will be contacted 6 months after discharge to offer follow-up training. This follow-up can take the form of telephone advice, with face-to-face contact if needed, every 6 months. Contact numbers for advice from the head and neck CNS team are: 0161 2063186 / 2068207. If a patient’s care is funded by the CCG, it is the CCG’s responsibility to ensure that the care agency chosen to provide care has a process to review competencies of the staff working with the patient. If a patient is discharged to a continuing health care facility, it is their responsibility to ensure that staff tracheostomy care is maintained at a local level.

6. Roles and responsibilities

Clinical Directors are accountable to the Medical Director for the implementation and adherence to this policy.

ADNSs are accountable to the Executive nurse for implementation and adherence to the policy.

ADOs will ensure the correct resources are available to ensure compliance with the policy.

Lead Nurses and Matrons are accountable for the implementation and adherence to the policy within their clinical areas.

Ward/Department Managers will ensure compliance with the policy. Leads for Speech and Language Therapy, Occupational Therapy and Physiotherapy will ensure compliance for therapy staff.

All staff caring for the patient with a tracheostomy will ensure they have the knowledge skills and competencies to do so and will comply with this policy.

7. Monitoring document effectiveness

7.1 This policy will be monitored by tracheostomy steering group.

An annual report of the policy will be presented to the clinical effectiveness committee by a member of the tracheostomy steering group. The policy will be reviewed every two years. The implementation of the policy will be monitored though the AIR system. Any breach resulting in an immediate AIR will be generated by the receiving ward and the Bed Management Team. On receipt of any AIR relating to patients with a tracheostomy, the receiving ward manager or team lead should inform tracheostomy steering group immediately.




.

8. Abbreviations and definitions

1. MDT – Multidisciplinary Team

2. CCG – Clinical Commissioning Group

3. CHC – Continuing Health Care

4. CNS – Clinical Nurse Specialist

5. NWAS – North West Ambulance Service

6. GP – General Practioner

7. DDN – Deputy Director of Nursing

8. DDN – Community Services

9. ADNS – Assistant Director of Nursing Services

10. ADO – Assistant Director of Operations

11. IDT – Integrated Discharge Team

9. References and Supporting Documents

9.1 North West Regional Tracheostomy Group (2010) Standards for the care of adult patients with a tracheostomy www.tracheostomy.org.uk National Tracheostomy Safety Project www.tracheostomy.org.uk Salford Royal NHS Foundation Trust. Tracheostomy and Laryngectomy MAIN DOCUMENT. Policy number: TWCG16 (11)a Available via local intranet. Intranet Website for local news and resources: http://intranet/clinical-services/dnrs/tracheostomy/?locale=en

Associated Documents: Tracheostomy and Laryngectomy Main Document. Policy number TWCG16(11)a

http://www.tracheostomy.org.uk/

http://www.tracheostomy.org.uk/

http://intranet/clinical-services/dnrs/tracheostomy/?locale=en

http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/twcg1611a/?locale=en




9.2 Standards All staff working with patients that are discharged from a hospital setting into the community should be made aware of this policy. It should be used by the MDT to facilitate a timely and safe discharge into the community setting. All staff must use the discharge checklist to ensure all relevant topics have been covered to ensure a safe discharge. It is the responsibility of the tracheostomy ward manager to have a good understanding of the policy and disseminate this information to all ward staff.




10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of

the document prior to submission for upload. Remove instructions once completed.

Nominated Lead author:

Claire Cooke and Sara Whitfield Specialist Neurological Physiotherapist) Specialist Physiotherapist in Neurological Rehabilitation

Lead author contact details:

0161 2062379

[email protected] [email protected]

Lead Author’s Manager:

Claire Guy Physiotherapist manager

Applies to: Please indicate which Care Organisation(s) this document applies to:

Salford CO

X

Oldham CO North Manchester CO

Bury & Rochdale CO

Northern Care Alliance Group (NCA)

Document developed in consultation with :

Endorsed by:

Name of Lead Clinician/Manager or Committee Chair

Position of Endorser or Name of Endorsing Committee

Date

Anna Perks Consultant Anaesthetist 10/4/2018

Krystyna Walton Consultant in Neurorehabilitation 10/4/2018

Paul Downes Head of Patient Safety 10/4/2018

Stephanie Jones Team Leader for Health 13/4/2018

Sara Barton Chair of the CEC 02/09/2019

Keywords/ phrases:

Discharge, Tracheostomy.

Communication plan:

Policy to be approved by the Clinical Effectiveness Committee Policy to be communicated to all relevant wards and departments through the governance structure. Policy to be published on the Tracheostomy web page on Synapse. Cascade information via lead nurse, lead clinician and matrons. Ward managers and therapy team leads with be responsible for the implementation of this policy. Ward managers will be responsible for tracheostomy management within their area of responsibility. Lead nurses will investigate AIRs in collaboration with the ward manager and action subsequent findings. Each ward that manages tracheostomy patients will identify an assigned a keyworker who will be responsible for ordering and collating the essential tracheostomy equipment before the patient is discharged. The ward manager’s role will involve:

Establishing access to appropriate equipment

Ensure that all staff are aware of the policy

Ensure that all discharge checklists in this policy are completed prior to

mailto:[email protected]




discharge

o Pre-discharge Risk Assessment

o Core tracheostomy training for carer/patient

o NWAS referral

o Discharge letter

Document review arrangements:

This policy will be monitored by tracheostomy steering group. An annual report of the policy will be presented to the clinical effectiveness committee by a member of the tracheostomy steering group. The policy will be reviewed every 3 years. The implementation of the policy will be monitored though the AIR system. Any breach resulting in an immediate AIR which will be generated by the reciving ward and the Bed Management Team. On receipt of any AIR relating to patients with a tracheostomy, the receiving ward manager or team lead should inform tracheostomy steering group immediately.

Approval: Clinical Effectiveness Committee 02/09/2019 Sara Barton Chair of the CEC Tracheostomy steering group. Lead: Anna Perks (consultant anaesthetist) / Andrew Deacon (consultant anaesthetist) / Delores Ragou (practice development nurse, clinical skills facilitator)

08/11/2018

How approved: Chair’s actions Formal Committee decision X




11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

Yes, staff Tracheostomy Steering Group Legal department

1b) Have any amendments been made as a result? If yes, specify what.

Yes

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?) x

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?) x

Race (e.g. any specific needs identified for certain groups such as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

x

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.) x

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?) x

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?) x

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?) x

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?) x

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?) x

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?) x

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

x

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

x




Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these?

Interpreters will be available for the patient of family/carers/parents who’s first language

isn’t English. Interpreters also including BSL for patients that would require it.

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken?

A patient with a disability would require support from a family and/or carer to support

decision making throughout the process or IMCA if this was required.

Will this policy require a full impact assessment? No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Andrew Deacon Date: 7/11/18 Claire Cooke 28/02/19

Sign off from Equality Champion: Date: 04/03/19





Appendix 1

Patient Name Telephone Number

Address

Post Code

Details to be entered (i.e. Medical History)

If Home Birth expected due date

Preferred Medical Pathway

GP Details

Address:

Postcode

Signature Patient/Relative

Duration of Warning long term altered airway patient ☐2 years

☐1 year

☐6 months

☐3 months

Processed by C3 Team

Date Entered Entered by

Review Date




The North West Ambulance Service has introduced a unique initiative to help those people in the community with a known medical or social risk. The Information Notification for Medical Emergencies (INFORM) Scheme allows anyone with disabilities, infirmity or long term illness to be registered on the NWAS computer system. How does the system work? By using and developing existing technology, the system reduces the communication between the caller and the Ambulance Control Staff. The computer recognizes the home telephone number and address of callers, callers registered details on the inform scheme enables a more rapid access to emergency medical care for their condition. Who can join the scheme? The scheme is provided free of charge to anyone who would benefit from inclusion. Anyone from Medical Practitioner to a concerned relative can register people on the scheme. Examples of those who would benefit from the scheme:

Laryngectomy patients or those with difficulty in communication.

People with long term illness or conditions with specific medical treatments, i.e.

Terminal patients

Oxygen therapy patients

Anaphylactic treatments

Those with access situations that may create difficulties for the responders, i.e.

Wheelchair access

This list can be exhaustive and is not exclusive to the above conditions, but consideration should be given to the information to be included to avoid over saturation of the system that would not be of benefit to the patient or responders. What is excluded? Patients who have Do Not Resuscitate or End of Life Care Plans in place are not covered by the Inform Scheme, these are dealt with using a different reporting system. How do I join? Simply by completing the registration documentation and returning it electronically to the email address below. In order to provide a fast and efficient emergency service, it is vitally important for you to inform us of any changes in the patients’ medical circumstances immediately. What will happen to my information? All information is entered directly in to the computer system and will be assessed in an emergency situation. It will be treated in the strictest confidence and will not be disclosed to third parties.




North West Ambulance Service is registered under the Data Protection Act to store such information. Should you require any further information or assistance, please do not hesitate to contact us on the email address below. Email: [email protected]





Appendix 2 Tracheostomy Passports

These passports are available from the Head and Neck Specialist nurses, or directly from

Kapitex.